Manzanita Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when: 1. A medication was stored in the refrigerator, not according to manufacturer's specification; 2. A medication was stored at room temperature, not according to manufacturer's specification; and 3. A discontinued medication was not removed from the medication storage room and was still accessible to the staff. These failures had the potential for medication misuse, drug diversion, medication ineffectiveness, and medication administration errors. Findings: 1. During an inspection on 2/4/25 at 9:37 a.m. of the facility's medication storage room, a discontinued, unopened medication, cyanocobalamin 1,000 micrograms/milliliters (mcg/ml; a unit of measure) was found stored in the refrigerator, not according to manufacturer's required storage parameters. A review of the manufacturer's package insert with a revised date of 2017, cyanocobalamin 1,000 mcg/ml, indicated to be stored between 68 degrees (a unit of measure) - 77 degrees Fahrenheit (scale of temperature).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the nutritive value of food was maintained, when broccoli was cooked for over two hours prior to lunch meal service. This failure had the potential of leading to nutrient deficiency for the 96 residents receiving facility prepared meals. Findings: During an observation on 2/4/25 at 9:48 a.m., in the kitchen, [NAME] 1 poured frozen broccoli into a pan and placed it into the convection oven to cook. During an observation on 2/4/25 at 12:22 p.m., in the kitchen, lunch meal service started. Observation of the broccoli showed a light green color, with a soft, limp texture when served. During the lunch meal on 2/4/25 at 1:15 p.m., two test trays were placed on the final meal cart (a regular diet and a pureed texture). The two test trays were picked up at 1:30 p.m. Food items tasted were: Regular pork with gravy, pureed pork with gravy, regular seasoned broccoli, pureed seasoned broccoli, and polenta. The broccoli was extremely soft…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food service safety, when: 1. Three baking sheets, one frying pan, one container for scoops, stove knobs, convention oven, and mixer were found dirty; 2. Ten pans, two frying pans, and blender were stored wet; 3. Pipes under three-compartment sink found rusted and dirty, floors were discolored with white and gray buildup, and counter had a white discolored area; 4. Yellow cutting board found with two deep grooves of about one and a half to two inches in length; 5. Four bulk storage containers were found with lids not closed tightly; and 6. Fan in dish machine area was found with black build-up on the blades. These failures had the potential to lead to food borne illness for the 96 residents eating facility prepared meals. Findings: 1. During the initial kitchen tour on 2/3/25 at 8:31 a.m., three baking sheets were found stacked under the steam table with dark…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide a resident refrigerator and microwave for a census of 96 to ensure safe food storage and reheating of food for later consumption. This failure had the potential to prevent residents from enjoying favorite foods, reduced resident food options, and potentially lead to weight loss. Findings: During an interview on 2/5/25 at 12:13 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated outside food would be checked against the diet order before it would be given to the resident. If a resident had left over food, it could not stay in the room for more than two hours before the facility would discard it. CNA 1 further stated that they do not refrigerate food for residents, because there was not a refrigerator and microwave for resident use. During an interview on 2/5/25 at 12:18 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated they advised family members against bringing perishable foods as the facility did not store or re-heat resident food. During an interview on 2/5/25 at 12:37 p.m. with CNA 2, CNA 2 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition, when: 1. The Walk-in freezer was found with ice build-up on ceiling, floor, door, walls, and fan unit indicating potential temperature changes; 2. The dish machine's required minimum temperatures were not reached; and 3. The convection oven was not achieving the desired food temperature for the pork at or above 165 degrees Fahrenheit (F, a unit of measurement). These failures had the potential of leading to food borne illness for the 96 residents eating facility prepared meals. Findings: 1. During a concurrent observation and interview on 2/3/25 at 8:51 a.m. with Dietary Manager (DM) in the walk-in freezer, the walk-in freezer was observed with ice build-up on the fan unit, ceiling, and pieces of ice on the floor. DM stated maintenance was in earlier removing ice build-up in the freezer which may be the cause of the ice on the floor. During an observation on 2/3/25 at 11:38 a.m., in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain respect and dignity for one of 22 sampled residents (Resident 439), when Resident 439's bilateral buttocks' sides were exposed in the hallway during transfer. This failure decreased the facility's potential to maintain Resident 439's respect and dignity. Findings: A review of an admission record indicated Resident 439 was admitted to the facility in 2024 with a diagnosis of panic disorder (a frequent and unexpected panic attack). During a concurrent observation and interview on 2/3/25 at 9:54 a.m. with Resident 439's daughter, Certified Nursing Assistant 3 (CNA 3) was wheeling Resident 439 on a shower chair in the hallway. Resident 439's bilateral buttocks' sides were not covered by the gown and were exposed to other residents, staff members, and Resident 439's daughter. Resident 439's daughter stated there was a respect and dignity issue when Resident 439's body was exposed. During an interview on 2/6/25 at 9:34 a.m. with the Director of Nursing (DON), DON stated staff should have covered Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide an appropriate communication method for one of 22 sampled residents (Resident 70), when Licensed Nurse 7 (LN 7) was unable to find a communication board to communicate with Resident 70. This failure decreased the facility's potential to address Resident 70's basic needs. Findings: A review of an admission Record indicated Resident 70 was admitted to the facility in 2024 with diagnoses including speech and language deficits. During a concurrent observation and interview on 2/4/25 at 8:53 a.m. with Resident 70 in her room, Resident 70 was unable to verbalize her needs and was using body language and gestures. During a concurrent observation and interview on 2/4/25 at 2:21 p.m. with LN 7 in Resident 70's room, LN 7 was unable to communicate with Resident 70 and started searching for the communication board inside Resident 70's room. LN 7 confirmed there was no communication board inside Resident 70's room and stated there should have been a communication board to help Resident 70 communicate with staff.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to keep one of 22 sampled residents (Resident 64) free of unnecessary psychotropic medication (drug prescribed to affect the mind, emotions or behavior), when Resident 64 was receiving divalproex sodium (a psychotropic medication indicated for seizure treatment and mood disorders) for an inadequate indication. This failure increased Resident 64's potential for unwanted adverse effects such as sedation and falls. Findings: A review of an admission record indicated Resident 64 was 78-years old, admitted in May 2024 to the facility from an acute care hospital with diagnoses including worsening disease of the nervous system, anxiety, depression, and dementia (a progressive state of decline in mental abilities) with behavioral disturbance. A review of Residents 64's Care Plan, dated 5/16/24, indicated Resident 64 was at risk for fall and injury related to her diagnoses. A review of Resident 64's Minimum Data Sets (MDS-an assessment tool), dated 5/23/24, 8/23/24, and 11/23/24, indicated a Brief Interview of Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices for three of 22 sampled residents (Resident 441, Resident 69, and Resident 290), when: 1. Licensed Nurse 6 (LN 6) did not change gloves during wound care treatment for Resident 441; 2. LN 6 did not follow proper handwashing and glove changing procedures during wound treatment for Resident 69; and 3. Resident 290's midline (a thin, flexible tube inserted into a vein in the upper arm and used to administer medicines and fluid directly into blood) dressing on left upper arm (LUA) was soiled and not changed for nine days. These failures decreased the facility's potential to prevent spread of infections among vulnerable residents. Findings: 1. A review of Resident 441's admission Record, indicated Resident 441 was admitted to the facility in 2024 with a diagnosis of sepsis (harmful microorganisms in the blood or other tissues that could potentially lead to malfunction of the organs, shock, and death). A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of physical abuse when Resident 1 was struck in the face by Resident 2. This failure resulted in Resident 1 sustaining a swollen bruise to her face and feeling unsafe. Findings: Resident 1 was admitted in the spring of 2024 with an admission diagnosis of irregular heartbeat. Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 out of 15 which indicated his cognitive function was moderately impaired. Resident 1 was her own responsible party. Resident 2 was admitted in the spring of 2024 with an admission diagnosis of spinal stenosis (a narrowing of the spinal canal that compresses the spinal cord and nerve roots, causing pain, numbness, or weakness in the arms or legs). Resident 2 had a BIMS score of 14 out of 15 which indicated she was cognitively intact and was her own responsible party. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light system for two of four sampled residents (Resident 3 and Resident 4) when neither the outside light above their room lit nor the alarm sounded when the emergency call light was pushed in the bathroom. This failure had the potential to result in unmet care needs and placed the residents at risk for safety. Findings: Resident 3 was admitted on [DATE] for a fracture of the right femur. Resident 3 has a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated the resident was cognitively intact and was her own responsible party. Resident 4 was admitted on [DATE] with a fracture of one rib. Resident 4 has a BIMS score of 12 out of 15 which indicated the resident was moderately impaired in cognitive function. Resident 4 was responsible party for self. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide care according to accepted standards of quality for one of 3 sampled residents (Resident 3) when Resident 3 had no documented behavior monitoring for the use of an antipsychotic medication (medication that affects brain activity associated with mental processes and behavior). This failure had the potential to result in an ineffective management of Resident 3's psychological health needs. Findings: A review of an admission Record for Resident 3 indicated she was admitted in 6/2024 with diagnoses including schizophrenia and bipolar disorder (mental illness that cause extreme mood swings that include emotional highs and lows). A review of Resident 3's Physician Orders, dated 6/25/24, indicated an order for Invega 156 milligrams (mg., a unit of measurement) per milliliter (ml., a unit of measure) given once a month for schizophrenia. A review of Resident 3's Progress Notes, dated 6/28/24 at 4:47 p.m., indicated that a nurse from a psychiatric clinic came to the facility and administered/injected Invega to Resident 3 as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to assess one of three sampled residents (Resident 1) at a high risk for elopement. This failure placed Resident 1 at an increased risk for elopement. Findings: A review of Resident 1's admission Record indicated she was admitted to the facility in May 2024 with diagnoses including unspecified dementia with behavioral disturbance. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used for care), dated 5/23/24, indicated that Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool) score of 4 out of 15, with memory problems. The MDS further indicated Resident 1 could independently transfer and ambulate using a walker. During observations on 7/1/24 at 11:40 a.m., 12:25 p.m., and 1:32 p.m., Resident 1 was observed ambulating alone without a walker by the hallways unable to go back to her own room without assistance. A review of Resident 3's Progress Notes, dated 6/24/24 at 6:43 p.m. and at 11:36 p.m., indicated Resident 3 exhibited verbal and physical aggression towards staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure that the Food/Nutrition Director had the qualifications needed to oversee the dietary department. This had had the potential of unsafe food practices and food borne illness for the 94 residents eating facility prepared foods. Findings: During an interview with the Food/Nutrition Director (FND) on 12/5/23 at 9:28 a.m. a certificate of education completion was not observed in his office. When asked about his path to becoming the Food/Nutrition Director, he stated he had experience running a kitchen under the direction of a Registered Dietitian (RD) but had no formal education. Review of California Health and Safety Code (HSC) § 1265.4 indicated that if A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. (b) The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 94 residents eating facility prepared meals as evidenced by: 1) Food preparation items were found dirty; 2) Food preparation and service equipment were found substandard; 3) Food service items were found stacked wet; 4) Opened containers were found in dry storage; 5) Multiple food items not correctly dated; 6) Fruit/vegetable sink lacked an air gap; and 7) Expired food produce. These failures had the potential to cause foodborne illness (illness that results from ingestion of contaminated food) to residents receiving food prepared in the facility kitchen. Findings: 1. During the initial kitchen tour on 12/4/23 at 9:01 a.m., the following food preparation items were found dirty: a. A metal container with utensils found to have food residue and crumbs; b. Food processor was found to have yellow and brown markings including the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure residents' rights were protected when entering into a binding arbitration agreement for a census of 97 when the agreement did not explicitly state the resident, or his or her responsible party (RP), had 30 days to rescind the agreement and did not contain an acknowledgement of the resident's or RP's understanding of the agreement. These failures had the potential to result in residents and/or their RPs entering into binding arbitration agreements without fully understanding the consequences. Findings: In an interview, on 12/4/23 at 8:49 a.m., the Administrator (ADM) stated the facility had asked residents and/or their RP's to enter into binding arbitration agreements. A review of the facility's binding arbitration agreement, on 12/5/23 at 10:51 a.m., indicated it did not contain an explicit statement the resident or RP had the right to rescind the agreement within 30 days of signing and did not include an acknowledgement of understanding by the resident or RP. In a concurrent record review and interview, on 12/7/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain the freezer in safe operating condition when ice buildup was noted on the door, curtains, walls and floor. This had the potential to affect the safety and quality of the food served at the facility for the 94 residents eating facility prepared meals. Findings: During the initial kitchen tour on 12/4/23 at 9:58 a.m., the freezer door was opened. On the back of the door was a build up of ice starting about 6 (inches) from the top of the door. The ice pattern was close to 1.5' (feet) in length and approximately 10 across at its widest point. The top portion of the ice curtains were also covered in ice as well as the right side walls, and ice was observed dripping from the pipes, and ice chunks had collected on the freezer floor. During a subsequent interview with the Maintenance Manager (MM) on 12/4/23 at 10:22 a.m., he stated that the leakage through the walls had been had fixed last month. He further explained that he wasn't aware that this was still a problem. During a return visit to the kitchen on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to: 1. Have an efficient system in place to accurately document and secure emergency medications (E-kit) for a census of 97; and, 2. Store controlled medications (those with high potential for abuse or addiction) to limit access in accordance with facility policy. These failures had the potential for emergency medications to be unavailable when needed, the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions, and potential for diversion of controlled medications. Findings: 1. During an inspection of the medication storage room on 12/4/23 at 11:27 a.m. with Director of Nursing (DON), the First Dose Oral Medications and Intravenous (into the vein) E-kits were sealed with red plastic ties indicating they had been opened by nursing staff. Inside the oral medications E-kit were nine E-kit logs (a document completed by nursing staff whenever a medication is removed from the emergency supply), with the earliest entry into the kit documented on 11/29/23. One of the nine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure two of 27 sampled residents (Residents 44 and Resident 71) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 44 received quetiapine (an antipsychotic) without target behavior monitoring and non-pharmacological (non-drug) interventions; and 2. Resident 71 received risperidone (an antipsychotic) without adequate indication and behavior monitoring. This failure had the potential to result in unnecessary use of medication. Findings: 1. Resident 44 was admitted to the facility in November 2023 with diagnoses which included post-traumatic stress disorder and major depressive disorder. A review of Resident 44's medical record (MR) indicated a physician's order for quetiapine 100 milligrams (mg, a unit of measurement), give 1 tablet at bedtime related to post-traumatic stress disorder m/b (manifested by) inability to relax, dated 11/8/23. Resident 44's MR indicated the facility was not monitoring for target behaviors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were stored safely for a census of 97 when: 1. Opened multi-dose medications and biologicals were dated with an open and discard date, expired medications were not available for resident use, pharmacy dispensed insulin (a medication to treat diabetes) were labeled, and medications were stored in the medication carts (med carts) in a safe and sanitary manner; and, 2. Medications were locked in a medication cart when unattended. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, receive incorrect medications from inadequate labeling and unsafe storage, and the potential for medication misuse and diversion. Findings: 1. During a concurrent observation and interview on 12/4/23 at 11:27 a.m. with Director of Nursing (DON), an inspection of the medication storage room refrigerator identified one vial Tubersol (an injectable used to diagnose exposure to tuberculosis, a bacterial disease that affects the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food served was palatable, attractive, and at a safe temperature for eight of 94 Residents (Resident 12, 23, 34, 39, 40, 184, 185, and 379) whose meals were delivered and served cold. These failures had the potential for decreased meal intake which could result in weight loss, decreased nutritive value, and negatively impact the residents' quality of life. Findings: During an interview on 12/04/23 at 09:19 a.m., Resident 379 stated, My breakfast was cold this morning including the sausage. During an interview on 12/4/23 at 9:50 a.m., Resident 40 stated, Food/soup is always cold and has no taste. During an interview on 12/4/23 at 9:59 a.m., Resident 34 stated, Soup was always served cold. During an interview on 12/04/23 at 10:52 a.m., Resident 12 stated, Today's breakfast was cold, the pancake and sausage were cold. The hot oatmeal was cold. I told the staff, and they responded the food was hot when it arrived. I wanted the food rewarmed and that did not happen. They seemed to be very busy, and I was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call lights were within reach for four residents (Resident 27, Resident 36, Resident 62, and Resident 380) of 27 sampled residents, when the call lights were stuck behind the residents' beds and dressers on the floor. This failure decreased the residents' potential to get assistance from staff in a timely manner when needed. Findings: A review of an admission record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body), dementia (impaired ability to remember, think, or make decisions), and history of falling. A review of an admission record indicated Resident 380 was admitted to the facility on [DATE] with diagnoses including dementia and shortness of breath. A review of an admission record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including parkinsonism (brain conditions that cause slowed movements and stiffness),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain dignity for one of 27 sampled resident (Resident 14) when Resident 14's catheter bag (a bag that collects urine from an indwelling urinary catheter) was exposed. This failure had the potential to reduce Resident 14's right to respect and dignity. Findings: A review of the facility document titled, admission Record, indicated Resident 14 was admitted to the facility in 2023 with diagnoses including kidney failure. During a concurrent observation and interview on 12/4/23 at 8:51 a.m., in Resident 14's room, Resident 14's catheter bag was hanging off the bed with brown urine inside without a privacy cover. Certified Nursing Assistant 1 (CNA 1) confirmed there was no privacy cover over the catheter bag. CNA 1 confirmed there should have been a privacy cover for Resident 14's catheter bag. During an interview on 12/6/23 at 10:06 a.m., the Director of Nursing (DON) stated staff should have placed a privacy cover over the catheter bag. Review of the facility's policy titled, Resident Rights, revised date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST, a medical order that gives patients control over their care during a medical emergency) forms for two residents (Resident 187 and Resident 378), of 27 sampled residents, were valid in the electronic health records (EHRs) when POLST information did not match with EHR. This failure decreased the staff's potential to safely follow the residents' POLST during emergencies. Findings: A review of Resident 187's admission record indicated he was admitted in 11/23 with diagnoses including heart failure and severe obesity. A review of Resident 187's clinical record included the following documents: A POLST, dated [DATE], indicated Resident 187 had elected Cardiopulmonary Resuscitation (CPR) if he were to be found without a pulse and not breathing and full treatment be provided if he were to be found to have a pulse and/or was not breathing. A physician's order, dated [DATE], indicated Resident 187…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to maintain a comfortable and safe living environment for one of 27 sampled residents (Resident 49) when the bed provided for Resident 49 was very small and worn out. This failure increased resident 49's potential for discomfort, sleep disturbances, and injury. Findings: A review of Resident 49's admission record indicated he was admitted in 6/2023 with diagnoses including generalized muscle weakness, and had the capacity to make healthcare decisions. A review of Resident 49's Minimum Data Set (MDS, an assessment tool) dated 7/2023, indicated Resident 49 had no memory problems with a Brief Interview of Mental Status (BIMS, a cognitive assessment tool) score of 13 out of 15. During a concurrent observation and interview on 12/4/23 at 10:09 a.m., with Resident 49, he was observed lying in bed with no foot board and noticed both feet hanging and sticking out over the bed, foot board at the corner by the wall. Resident 49 stated maintenance staff had to take it off because he hits his heels on it whenever he moves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in a timely manner for one of 27 sampled residents (Resident 47). This failure had the potential of not providing appropriate care and interventions to Resident 47 based on her current status. Findings: Resident 47 was admitted in 6/2023 with diagnoses including metastatic lung cancer (cancer that spread from its origin in the lung), and dementia and did not have capacity to make their own choices. The daughter was listed as the responsible party (RP) who makes healthcare decisions. A review of facility MDS Brief Interview of Mental Status (BIMS, an assessment tool) score was 6 out 15, indicating severe cognitive impairment. During a review of Resident 47's Order Listing Report (OLR), indicated Resident 47 was admitted under hospice care (specialized treatment for people with serious illness or end of life care) and was discharged from the hospice program per physicians' order on 11/8/23, due to an extended prognosis. During a concurrent interview and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess one resident (Resident 36) of 27 sampled residents, when the Minimum Data Set (MDS; an assessment tool) inaccurately indicated Resident 36 had no behaviors. This failure decreased the facility's potential to identify residents' care needs. Findings: A review of an admission record indicated Resident 36 was admitted to the facility in June 2021 with diagnoses including Alzheimer's disease (a brain disorder), dementia (impaired ability to remember, think, or make decisions), and major depressive disorder. A review of Resident 36's Order Summary Report, dated 10/31/23, indicated Resident 36 started to receive 2.5 milligrams (mg; a unit of measure) of olanzapine (an antipsychotic medication) at bedtime for agitation manifested by yelling out. A review of Resident 36's MDS, dated [DATE], indicated Resident 36 exhibited no verbal behavioral symptoms directed toward others. A review of Resident 36's Medication Administration Record (MAR),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan for one resident (Resident 16) of 27 sampled residents within 48 hours after admission. This failure decreased the facility's potential to address the residents' initial goals and current health needs. Findings: A review of an admission record indicated Resident 16 was admitted to the facility on [DATE], with diagnoses including pneumonia (lung infection) and dialysis (treatment for kidney failure). A review of Resident 16's 48 Hour Baseline Care Plan, indicated the baseline care plan was completed on 11/17/23. During an interview on 12/6/23 at 2:42 p.m. with the Resources Nurse Consultant (RNC), RNC confirmed Resident 16's baseline care plan was not completed within 48 hours after admission. RNC stated the baseline care plan should have been completed within 48 hours because nurses could use it as a tool to get an idea about the resident's care and services and what areas to focus on and it would also help in the discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one resident (Resident 36) of 27 sampled residents, when the care plan did not address Resident 36's behavioral needs and interventions. This failure decreased the facility's potential to address the residents' individualized and specific needs. Findings: A review of an admission record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder), dementia (impaired ability to remember, think, or make decisions), and major depressive disorder. A review of Resident 36's Order Summary Report, dated 10/31/23, indicated Resident 36 started to receive 2.5 milligrams (mg; a unit of measure) of olanzapine (an antipsychotic medication) at bedtime for agitation manifested by yelling out. A review of Resident 36's Order Summary Report, dated 11/1/23, indicated to monitor Resident 36 for yelling out every shift. During an interview on 12/6/23 at 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for two residents (Resident 36 and Resident 47) of 27 sampled residents, when: 1. Resident 36's oxygen was not administered as indicated in physician's order; and, 2. Resident 47's physician order for the use of an external catheter was not obtained. These failures had the potential to jeopardize resident health when physician orders were not obtained or followed. Findings: 1. A review of an admission record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including palliative care (specialized medical care for people living with a serious illness), dementia (impaired ability to remember, think, or make decisions), tobacco use, and chronic obstructive pulmonary (lung) disease. A review of Resident 36's Minimum Data Set (MDS; an assessment tool), dated 11/10/23, indicated Brief Interview of Mental Status (BIMS) score was two of 15 with memory loss. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to assist one of 27 sampled residents (Resident 61) to receive a hearing assessment when Resident 61 had difficulty hearing. This failure decreased Resident 61's ability to communicate needs properly and negatively affected her psychosocial well-being. Findings: Resident 61 was admitted in early 7/2023 with diagnoses including recurrent major depressive disorder, able to understand choices and make own healthcare decisions. Resident 61 had intact memory and a Brief Interview of Mental Status (BIMS, an assessment tool) score of 14 out of 15. A review of Resident 61's admission notes, dated 7/12/23, indicated the admitting nurse noted a report from the acute hospital that Resident 61 was hard of hearing. A review of the social services notes, dated 7/13/23, indicated Resident 61 used hearing aids, but were left at home. A review of Resident 61's physical examination, done on 8/15/23, the Physician confirmed Resident 61 had moderate bilateral hearing loss. During a concurrent observation and interview on 12/4/23, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide respiratory care for one of 27 sampled residents (Resident 185) when a Continuous Positive Airway Pressure machine (CPAP; a machine that uses mild air pressure to keep breathing airways open while sleeping) treatment had not been applied nightly as ordered by the physician (MD). This failure had the potential to negatively impact Resident 185's sleep and respiratory status. Findings: A review of Resident 185's admission record indicated she was admitted in 12/23 with diagnoses including acute respiratory failure with hypoxia (low blood oxygen levels) and obstructive sleep apnea (intermittent airflow blockage during sleep). The record also indicated Resident 185 was her own responsible party (RP). An MD order, dated 12/1/23, indicated Resident 185 was to wear a CPAP at night while sleeping. A MAR (Medication Administration Record), dated 12/23, indicated Resident 185 had worn the CPAP at night 12/1/23- 12/5/23. An Administration Note, dated 12/4/23, indicated Resident 185 was not using the CPAP machine.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to provide medically related social services for one of 27 sampled residents (Resident 45) when Resident 45's request to acquire a 4-wheeled walker with a seat was not facilitated in a timely manner. This failure had the potential to decrease Resident 45's ability to maintain her highest practicable physical well-being. Findings: Resident 45 was admitted in 9/2021 with diagnoses including transient ischemic attack (TIA, mini stroke disruption of blood supply to the brain). Resident 45 did not have the capacity to make own healthcare decisions, and required supervision assistance for locomotion on/off the unit in a wheelchair and with ambulation using a walker. During a concurrent observation and interview on 12/4/23 at 8:41 a.m. Resident 45 was walking by the hallway while using her wheelchair as a walker. Resident 45 stated she's been requesting a walker with a seat for a long time, but never got it, and her wheelchair stops suddenly whenever she propels in it, that was the reason why she just used the wheelchair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for one resident (Resident 36) of 27 sampled residents, when the Medication Administration Record (MAR) did not include Resident 36's use of oxygen. This failure increased the facility's potential for oversight in Resident 36's assessment, care, and treatment. Findings: A review of an admission record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including palliative care (specialized medical care for people living with a serious illness), dementia (impaired ability to remember, think, or make decisions), tobacco use, and chronic obstructive pulmonary (lung) disease. A review of Resident 36's Care Plan, dated 11/15/23, indicated Resident 36 was a smoker. During an observation on 12/4/23 at 9:38 a.m., in Resident 36's room, Resident 36 was lying in his bed and connected to oxygen at three liters per minute via nasal cannula (a device that delivers extra oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to establish and maintain infection control practices designed to provide a sanitary environment for one of 27 sampled residents (Resident 129) when staff did not maintain hand hygiene practices and change gloves during wound care. This failure had the potential to result in transmission of infection in the facility and cause illness. Findings: Review of the admission Record, Resident 129 was admitted to the facility in 2023 with diagnoses including a pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) on the buttock. During an observation on 12/5/23 at 3:06 p.m., with Licensed Nurse 3 (LN 3) during wound care for a right buttock wound for Resident 129, LN 3 was preparing wound care supplies, touched the trash can, removed the soiled dressing, cleaned the wound, and applied the new dressing using the same gloves. During an interview on 12/5/23 at 3:19 p.m., LN 3 confirmed she should have changed gloves and maintained hand hygiene practice during wound care.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.